eMedicine Specialties > Emergency Medicine > Trauma & Orthopedics

Fracture, Humerus: Differential Diagnoses & Workup

Author: Andrew A Aronson, MD, Assistant Professor of Emergency Medicine, Drexel University School of Medicine; Consulting Staff, Department of Emergency Medicine, Allegheny General Hospital
Coauthor(s): Adarsh K Srivastava, MD, Staff Physician, Department of Emergency Medicine/Internal Medicine, Allegheny General Hospital
Contributor Information and Disclosures

Updated: Oct 28, 2009

Differential Diagnoses

Dislocations, Shoulder
Fractures, Clavicle
Fractures, Elbow
Fractures, Scapular

Other Problems to Be Considered

  • A humerus fracture in a child with an inconsistent injury mechanism should raise suspicion for abuse and trigger further investigation.
  • Fractures that occur spontaneously, without apparent injury, suggest a pathologic fracture.
  • Young patients presenting with humeral diaphyseal fractures after high-energy injuries frequently have multiple injuries. Approximately 5% of these patients with humeral diaphyseal fractures present with spinal fractures or complex foot fractures, and about 4% present have pelvic or proximal tibial fractures.8
  • Older patients tend to present with other fractures in the ipsilateral arm, usually distal radius fractures.8
  • Radial nerve palsy associated with fractures of the shaft of the humerus is the most common nerve lesion complicating fractures of long bones.10

Workup

Imaging Studies

  • For the distal and diaphyseal humeral fractures, anteroposterior and lateral views of the humerus, as well as transthoracic and axillary views of the shoulder, should be adequate to visualize a fracture.
  • CT scans are helpful if radiographs are unclear.
  • Proximal humerus fracture
    • The humeral head articulates with the scapular glenoid.
    • The proximal humerus has 4 parts: articulating surface (anatomical neck), greater tuberosity, lesser tuberosity, and humeral shaft. The surgical neck is just distal to both tuberosities.
    • The minimum baseline studies for the evaluation of proximal humeral fractures must include a true anteroposterior (AP) view of the scapula and glenohumeral joint, an axillary view, and a lateral Y view of the scapula, evaluating the glenohumeral joint and proximal humerus in 3 perpendicular planes.11
    • All greater tuberosity fractures should, at some point, have an ultrasound examination or an MRI to check the integrity of the rotator cuff.
    • Blood is supplied to the humeral head from branches off the axillary artery. Blood travels distally to proximally. Fractures of the anatomical neck may affect blood supply and result in avascular necrosis of the humeral head.
  • Neer classification system is the commonly used terminology to describe proximal humerus fractures.3
Neer classification.

Neer classification.

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Neer classification.

Neer classification.


    • If any of the 4 segments is separated by more than 1 cm from its neighbor or is angulated more than 45°, the fracture is said to be displaced.
    • One-part fractures are nondisplaced fractures or fractures with minimal displacement.
    • Two-part fractures are fractures in which only a single segment is displaced in relation to the other three.
    • Three-part fractures occur when two segments are displaced in relation to the other two parts.
    • Four-part fractures exist when all the humeral segments are displaced.
    • Operative treatment decisions are based primarily on the number of segments involved and degree of displacement. Most fractures are displaced minimally and treated conservatively. Often, 3- and 4-part fractures require surgical management due to damage of the vasculature of the humeral head.
  • Diaphyseal fractures - Classified as simple, wedge, or complex (comminuted)

More on Fracture, Humerus

Overview: Fracture, Humerus
Differential Diagnoses & Workup: Fracture, Humerus
Treatment & Medication: Fracture, Humerus
Follow-up: Fracture, Humerus
Multimedia: Fracture, Humerus
References
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References

  1. Kontakis G, Koutras C, Tosounidis T, Giannoudis P. Early management of proximal humeral fractures with hemiarthroplasty: a systematic review. J Bone Joint Surg Br. Nov 2008;90(11):1407-13. [Medline].

  2. Cheung EV, Sperling JW. Management of proximal humeral nonunions and malunions. Orthop Clin North Am. Oct 2008;39(4):475-82, vii. [Medline].

  3. Neer CS 2nd. Displaced proximal humeral fractures. I. Classification and evaluation. J Bone Joint Surg Am. Sep 1970;52(6):1077-89. [Medline].

  4. Brukner P. Stress fractures of the upper limb. Sports Med. Dec 1998;26(6):415-24. [Medline].

  5. Ogawa K, Yoshida A. Throwing fracture of the humeral shaft. An analysis of 90 patients. Am J Sports Med. Mar-Apr 1998;26(2):242-6. [Medline].

  6. Pehlivan O, Kiral A, Akmaz I, Solakoglu C, Arpacioglu O, Kaplan H. Humeral shaft fractures secondary to throwing. Orthopedics. Nov 2003;26(11):1139-41. [Medline].

  7. Court-Brown CM, Caesar B. Epidemiology of adult fractures: A review. Injury. Aug 2006;37(8):691-7. [Medline].

  8. Brown CC, McQueen MM, Tornetta III P. Orthopedic Surgery Essentials: Trauma. Philadelphia, Pa: Lippincott Williams and Wilkins; 2006:89-114.

  9. Baron AA, Barrett JA, Karagas MR. The epidemiology of peripheral fractures. Bone. 1996;18:209S-13S.

  10. Shao YC, Harwood P, Grotz MR, Limb D, Giannoudis PV. Radial nerve palsy associated with fractures of the shaft of the humerus: a systematic review. J Bone Joint Surg Br. Dec 2005;87(12):1647-52. [Medline].

  11. Robinson BC, Athwal GS, Sanchez-Sotelo J, Rispoli DM. Classification and imaging of proximal humerus fractures. Orthop Clin North Am. Oct 2008;39(4):393-403, v. [Medline].

  12. Anglen JO, Archdeacon MT, Cannada LK, Herscovici D Jr. Avoiding complications in the treatment of humeral fractures. J Bone Joint Surg Am. Jul 2008;90(7):1580-9. [Medline].

  13. Byrd RG, Byrd RP Jr, Roy TM. Axillary artery injuries after proximal fracture of the humerus. Am J Emerg Med. Mar 1998;16(2):154-6. [Medline].

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  20. Szyszkowitz R, Seggl W, Schleifer P, Cundy PJ. Proximal humeral fractures. Management techniques and expected results. Clin Orthop Relat Res. Jul 1993;13-25. [Medline].

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  22. Warner JP, Costouros JG, Gerber C. Fractures of the proximal humerus. In: Bucholz RW, Heckman JD, Brown CC, eds. Rockwood and Green's Fractures in Adults. Vol 1. 6th ed. Philadelphia, Pa: Lippincott Williams and Wilkins; 2006:1161-1205.

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Further Reading

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Keywords

broken humerus, humerus fracture, fractured humerus, broken arm, broken shoulder, shoulder fracture, arm fracture, forearm fracture

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Contributor Information and Disclosures

Author

Andrew A Aronson, MD, Assistant Professor of Emergency Medicine, Drexel University School of Medicine; Consulting Staff, Department of Emergency Medicine, Allegheny General Hospital
Andrew A Aronson, MD is a member of the following medical societies: American College of Emergency Physicians, Massachusetts Medical Society, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Coauthor(s)

Adarsh K Srivastava, MD, Staff Physician, Department of Emergency Medicine/Internal Medicine, Allegheny General Hospital
Adarsh K Srivastava, MD is a member of the following medical societies: American College of Emergency Physicians, Emergency Medicine Residents Association, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Medical Editor

Michelle Ervin, MD, Chair, Department of Emergency Medicine, Howard University Hospital
Michelle Ervin, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, National Medical Association, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Eric L Legome, MD, Chair, Department of Emergency Medicine, St Vincent's Hospital Manhattan; Associate Professor, Department of Emergency Medicine, New York Medical College
Eric L Legome, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, Council of Emergency Medicine Residency Directors, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

CME Editor

John D Halamka, MD, MS, Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center
John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Chief Editor

Rick Kulkarni, MD, Assistant Professor of Surgery, Section of Emergency Medicine, Yale-New Haven Hospital
Rick Kulkarni, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: WebMD Salary Employment

 
 
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